Tibialis posterior tendinitis
Also known as: tendinopathy, tenosynovitis, enthesopathy, posterior tibial dysfunction, tendinosis
The term “tendinitis” comes from tendin (tendon) and itis (inflammation). Tibialis posterior tendinitis refers to inflammation of a major tendon that runs through your inner ankle and foot. The tibialis posterior muscle originates in the calf, runs along the inner ankle and inserts into most of the bones that form the arch of your foot. Most often, tibialis posterior tendinitis is a chronic degenerative condition. Pain can occur out of the blue, without being associated with a traumatic event. In such cases, it’s more accurately called tendinosis or tendinopathy.
Signs and symptoms of a tendinopathy
- Pain in the inner ankle and/or foot arch
- Pain on a bone in the foot arch
- Pain typically occurs when you take your first steps in the morning or after a long period of rest
- Pain may get worse over the course of the day or during physical activity
- A lengthening, stretching or tearing sensation in the inner ankle
- Burning sensation (in some cases)
- Cramping or stiffness in calf muscle
- Swelling, redness and/or warmth in the inner ankle or foot
- Tingling or shocks in the ankle and under the foot
- Fallen arches
- Difficulty walking on tiptoes
What are the causes of a posterior tibial dysfunction
The tibialis posterior muscle is used for most foot functions. It supports the arch and helps keep your foot stable. When you walk, it helps slow the foot down as it strikes the ground, helps absorb shock and helps with propulsion. A problem with one of these functions can put excessive strain on the muscle and result in injury to the tendon. Eventually, the tendon can degenerate and cause pain. Most often, poor foot mechanics are the root cause of the problem.
The most common causes of stress/overuse of the posterior tibial tendon include :
- Flat feet and fallen arches/hyperpronation
- Bunions and/or dysfunction of the big toe
- Stiff calf muscles
- Joint hypermobility (excessive foot flexibility)
- Leg length discrepancy
- Flexible high arches
In rarer cases, posterior tibial tendonitis can result from traumatic incident that damages the tendon and causes it to swell:
- Sprained ankle (especially the inner ankle)
- Fractured ankle
- An accident (such as stepping into a hole)
- Poor circulation
- Inflammatory disease
- Old age
Progression and consequences of a tenosynovitis or a tibialis posterior tendinitis
Initially, you may only feel slight discomfort in your inner ankle or foot arch, especially after prolonged activity. The pain may then recur more frequently and become constant, to the point that it becomes incapacitating.
When the tendon is continually strained, it progressively degenerates and becomes longer. As the foot becomes flatter, you may find it harder to rise onto tiptoes, go up and down stairs, etc. If the tendon degenerates further, it may fissure or tear. This can inhibit its function even more. Ultimately, the tendon can rupture completely.
In addition, an inflamed posterior tibial tendon and sheath can irritate surrounding tissues, including a major nerve. This can lead to numbness, tingling or a burning sensation in the inner ankle or foot arch. This is called tarsal tunnel syndrome.
Finally, if the posterior tibial tendon is weakened and stops functioning properly, the stabilizer muscles in your foot will be forced to compensate. Over time, they can tire and start to hurt too. As a result, you may change your gait or limp, and the change in your posture can trigger pain in your knees, hips, back, etc.
How to treat a posterior tibial tendonitis at home :
There are three aspects to treating posterior tibial tendonitis:
1 – Improving foot mechanics :
- Wear laced shoes with a bit of a heel, like running shoes, as often as possible, even at home.
- Temporarily fit your shoes with prefab insoles with arch support.
- Reduce physical activity that involves putting weight on the foot and opt for swimming or cycling instead.
2 – Managing the inflammation :
- Apply ice to the painful area 10-15 minutes every evening and throughout the day as needed. Tip: Wrap your bag of ice or frozen peas around your ankle and secure to your ankle/foot with a tensor bandage.
- Take anti-inflammatory medication such as Advil or Aleve, as indicated on the product package and only if your health permits.
3 – Stretching exercises :
- Warm up your feet when you step out of bed in the morning. Rotate your ankles and flex your foot to stretch the calf muscle.
- Gently stretch your calves every morning and evening. If it’s not too painful for you, you can use a wall, step or folded towel as a prop. You should feel a stretch, but it should not be painful.
Diagnostic of a posterior tibial tendonitis
- A thorough biomechanical exam is used to determine whether a mechanical problem is causing excessive strain on the tibialis posterior. If there a mechanical problem and it is not addressed, the pain will recur or never fully go away. A biomechanical exam involves analyzing your gait using pressure sensors and special cameras.
- X-rays are also needed to see how the tibialis posterior inserts in the tarsal bones, to determine whether calcium deposits are irritating the tendon and to make sure there isn’t an extra bone causing a problem. X-rays also make it possible to verify the alignment of the bones in your foot and compare it with your healthy foot.
- Ultrasound is an excellent imaging technique used to assess the condition of the tendon and sheath. After the severity of the problem has been determined, we can develop a suitable treatment plan. This radiation-free technique allows us to observe the inflamed/degenerated area, measure the thickening of tissue, assess blood flow to the tendon and its fibre structure, and determine whether tears are present. It also allows us to rule out other conditions affecting the surrounding structures.
What can my podiatrist do about a posterior tibial dysfunction?
The podiatrist’s primary goal is to diagnose the condition and its severity. The second goal is to determine the cause and develop a treatment plan in order to ease the pain and prevent the problem from recurring over the long term.
Some solutions include:
1. Plantar orthotics
Plantar orthotics are custom-made for each patient. They address specific issues to limit excessive strain on your tendon. This prevents further degeneration and promotes healing. Plantar orthotics can help you get back on your feet faster and contribute to prevent future problems.
2. Ankle braces
If you have a severe case of tibialis posterior tendinitis, you may need to wear an ankle brace while you recover. Patients are advised to wear an ankle brace if their foot function has been compromised severely (for example, if you have trouble raising your heel off the ground). Your podiatrist will help you choose the right brace for your condition.
3. Prescription medication:
Painkillers, muscle relaxants and/or anti-inflammatory drugs may be prescribed.
4. Physical therapy:
- Manipulative therapy is sometimes used to release the tendon and calf muscle so that the tendon can move with greater ease. It can also help realign the bones in flat feet.
- Cryotherapy and ultrasound treatments are used to treat inflammation.
- Taping is used to support the foot and ankle, allowing the tibialis posterior to rest. Taping can sometimes help improve circulation and reduce swelling.
5. Radial shockwave therapy
Used in chronic, treatment-resistant cases, radial shockwave therapy uses the body’s natural capacities to restart the healing cycle. Find out more about the radial shockwave therapy.
6. Ultrasound-guided cortisone injections
Ultrasound-guided cortisone injections are only used in rare cases when the swelling comes from the tendon sheath. It’s important to avoid injecting into a degenerated tendon as there is a high risk of rupture. That’s why we use ultrasound to accurately pinpoint the injection site.
How to prevent a tendinosis?
- Wear your custom orthotics every day to prevent your tibialis posterior from being overused and degenerating.
- Choose good footwear and avoid shoes that are flat, too flexible or offer no support (such as canvas sneakers or ballerina slippers).
- Replace your shoes and work boots annually.
- Wear supportive sandals or running shoes whenever you spend long periods standing at home (while cooking, etc.).
- Seek treatment as soon as you feel pain to prevent long-term problems (See “Treating the condition at home”)
- If overweight, consider losing weight.
- Warm up well before doing sports or other physical activities.
- After exercising, it’s important to stretch the calves and the backs of the legs.
- Follow a progressive workout plan, particularly if you run.
- Have your foot mechanics assessed, ideally before symptoms occur.
My arch is falling, but since it doesn't hurt, I don’t need to see a doctor.
If you notice your arch falling, there’s a good chance that your tibialis posterior is being overused. It’s important to see a doctor before it starts to hurt so that you can prevent tendon degeneration.
What if it’s not tibialis posterior tendinitis/tendinosis?
A number of other conditions can cause similar symptoms, such as:
- Navicular avulsion fracture
- Navicular stress fracture
- Tarsal tunnel syndrome
- Osteoarthritis of the ankle or foot (tarsal bones)
- Sprained or fractured ankle
- Tendinopathy of the flexor hallucis longus muscle
- Tendinopathy of the flexor digitorium muscle
- Tendinopathy of the tibialis anterior muscle
- Accessory navicular bone
- Referred pain (lumbar compression)
- Tumor in the inner ankle
- Systemic disease (rheumatoid arthritis, fibromyalgia, psoriatic arthritis, ankylosing spondylitis, etc.)